TheDeathwithDignityActcontinuestobethefocusofhighlychargedethical,legal,andmedicaldebates.The role of the Oregon Health Division is neither to take sides nor to settlethesecontroversies;however,webelievethatthedatacollectedon1998participantsintheDeathwithDignityActandonpatientswhochosephysician-assistedsuicideareimportanttoallconcernedparties. Among the important findings from our 1998 data collection and comparison studiesare:

•Physician-assistedsuicideaccountedforapproximately5ofevery10,000 deaths in Oregon in 1998. Patients with cancer who chosephysician-assistedsuicide accounted for 19 of every 10,000 cancer deaths in Oregon in1998.

•Patientswhochosephysician-assistedsuicidein1998weresimilartoallOregonianswhodiedofsimilarunderlyingillnesseswithrespecttoage,race,sex, and Portlandresidence.

•In1998,manyhospitalsandphysiciansinOregonwereunableorunwillingtoparticipate in physician-assistedsuicide.

•Physicianswhowroteprescriptionsforlethalmedicationsforpatientswhochosephysician-assistedsuiciderepresentedawiderangeofspecialties,ages,and years inpractice.

Considerabledebatehasfocusedonthecharacteristicsofterminally-illpatientswhochoosephysician-assisted suicide. Some feared that patients who were minorities, poor, oruneducatedwould more likely be coerced into choosing physician-assisted suicide. Others fearedthat terminally-illpersonswouldfeelpressured,eitherinternallyorthroughexternalforces(e.g.,familymembersorhealthcaresystems),tochoose physician-assistedsuicidebecauseofthefinancial impact of their illnesses.To date, the Oregonians who have chosenphysician-assistedsuicidehavenothadthesecharacteristics.

Patientswhochosephysician-assistedsuicideandourtwocomparisongroupsweresimilarwithrespecttoage,sex,race,educationlevel,andhealthinsurancecoverage.Nopersonwhochosephysician-assistedsuicideexpressedaconcernto their physician about the financial impact of their illness. The proportion of patientswithprivateinsuranceandmedicaidweresimilaramongthosewhochosephysician-assistedsuicideand among controls. This provides some evidence that socioeconomic status was notassociatedwiththedecisiontotakelethalmedications.

EndoflifecarehasmadegreatstridesinOregoninrecentyears.Oregonranksthird,nationally,in the rate of hospice admissions.More than two-thirds of the patients who chosephysician-assisted suicide were enrolled in a hospice program when they died. A similar proportionofcontrolpatientswerealsoenrolledinhospice.Ofthefourpatientswhochosephysician-assistedsuicide,butwhowerenotreceivinghospicecare,threehadrepeatedlyrefusedenrollmentoffers.To date, lack of access to hospice care has not been associated with the decision to takelethalmedications. Fear of intractable pain was also an end of life care issue not associatedwithphysician-assisted suicide. Only one person who chose physician-assisted suicideexpressedconcerntoherphysicianaboutinadequatepaincontrolattheendoflife(comparedwith15of43 control patients). This may reflect confidence in one’s end of life care. Alternatively,recipientsoflethalmedicationsmaynothavebeenconcernedaboutendoflifepainbecausephysician-assistedsuicideofferedthemtheoptionofavoidingintractablepain.

TheprimaryfactordistinguishingpersonsinOregonselectingphysician-assistedsuicideisrelatedto the importance of autonomy and personal control. Patients who chosephysician-assistedsuicideweremorelikelytobeconcernedaboutlossofautonomyandlossofcontrolofbodilyfunctionsthancontrolpatients.*Autonomywasaprominentpatientcharacteristicinphysicians’ answers to open-ended questions about their patients’ end of life concerns. Manyprescribingphysiciansreportedthattheirpatientsdecisiontorequestalethalprescriptionwasconsistentwitha long-standing philosophy about controlling the manner in which they died.The fact that79% ofpersonswhochosephysician-assistedsuicidedidnotwaituntiltheywerebedriddentotaketheirlethalmedicationprovidesfurtherevidencethatcontrollingthemannerandtimeofdeathwere important issues to these patients. Thus, in Oregon the decision to request and useaprescription for lethal medications in 1998 appears to be more associated with attitudesabout autonomyanddying,andlesswithfearsaboutintractablepainorfinancialloss.

There are several limitations that are important to consider when interpreting these results.First,thenumberofpatientswhochosephysician-assistedsuicidein1998wasrelativelysmall.Thislimits our ability to detect, from a statistical standpoint, small differences betweenthecharacteristics of persons who chose physician-assisted suicide and control patients. Second,thepossibilityofphysicianbiasmustbeconsidered.Physiciansprescribinglethalmedicationsmayhavespentmoretimeexploringendoflifeconcernsandcareoptionswithpatientswhorequestedlethalmedications.Becauseoftheuniquenatureoflethalprescriptionrequests,physiciansmayhaverecalledtheirconversationsandinteractionswithrequestingpatientsingreaterdetailthanphysiciansofterminallyillpatientswhodidnotrequestsuchprescriptions.Finally,theDeathwithDignityActrequirestheOHDtocollectdataonpatientsandphysicianswhoparticipateinthe Act.However, the OHD must also report any noncompliance with the law to theOregonBoardofMedicalExaminersforfurtherinvestigation.Becauseofthisobligation,wecannot detect or collect data on issues of noncompliance with any accuracy. A 1995 anonymoussurveyofOregonphysiciansfoundthat7%ofsurveyedphysicianshadprovidedprescriptionsforlethalmedications to patients prior to legalization.We do not know if covertphysician-assistedsuicidecontinuedtobepracticedinOregonin1998.

Considerabledebatehasalsosurroundedtheinterpretationofverylimiteddataonthemedicationsprescribedforphysician-assistedsuicideandtherapidityoftheireffects.Withoneexception,allofthelethalprescriptionsweresimilar.ThismayreflectinformationavailablefromOregonphysician-assisted suicide advocacy groups. Although all patients were unconscious within20 minutesofmedicationingestion,thetimefromingestiontodeathrangedfrom15minutesto11.5 hours. In four instances, patients died more than 3 hours after taking the medications,includingthe one patient who died 11. 5 hours afterward. The last patient fell asleep 5 minutes aftertakingall 9 grams of barbiturate, the same prescription given to 14 of the 15 persons whochosephysician-assistedsuicide.Physicians,patients,andtheirfamiliesshouldbeawarethatthetimefrommedicationingestiontodeathisnotalwaysrapidorpredictable.

In1998,notallhospitalsystemsorphysiciansinOregonparticipatedinphysician-assistedsuicide.FederallawprohibitsparticipationbypatientsorphysicianswithinfederalhealthcaresystemssuchasVeteransAdministrationHospitalsandIndianHealthServiceclinics.Somehealthcaresystems,includingatleastoneCatholicmedicalsysteminOregon,haveplacedsimilarrestrictionsonpatientsandstaffwithintheirfacilities.AlthoughsomephysiciansareunabletoparticipateintheDeathwithDignityActbecauseofrestrictionsbytheiremployers,otherphysicianshave chosen not to participate in physician-assisted suicide because of other concerns. Six ofthepatientswhochosephysician-assistedsuicidehadtoapproachmorethanonephysicianbeforefindingonethatwouldstarttheprescriptionprocess.Two-thirdsofotherwiseeligiblecontrolpatients,hadtheyasked,wouldnothavereceivedsuchprescriptionsfromthephysicianthatweinterviewed.BothfindingsprovideevidencethatasubstantialproportionofOregonphysiciansarenotwillingtoparticipateinlegalizedphysician-assistedsuicide.

Physicianswhowroteprescriptionsforlethalmedicationsforthosepatientswhochosephysician-assistedsuiciderepresentedawiderangeofmedicalspecialties,ages,andyearsinpracticeandwere similar to physicians for control patients with respect to these characteristics.SeveralOregonphysicianshavepubliclyacknowledgedtheirparticipationintheDeathwithDignityAct,but the majority of prescribing physicians have remained anonymous. Severalphysicianscommentedthatdespitetheemotionalimpactofparticipatinginaphysician-assistedsuicide,theywereunwillingtosharetheirexperiencewithothersbecausetheyfearedrepercussionsfromcolleaguesorpatientsiftheydidnotkeeptheiridentityasaDeathwithDignityActparticipant anonymous.

Inpublishingthisreport,werecognizethattheDeathwithDignityActhasbeenandremainsafocal point for ethical, legal, and medical debate. As required by the Act, we will continuetocollectinformationregardingcompliancewiththestatute,andweemphasizethatourroleistodo so as a neutral party. In accordance with the Act, we will make available to the public anannualstatistical report of the information collected. Future reports may not, however, contain thelevelofdetailprovidedinthisfirststudy.